Patient Survey

Premier Imaging

We’d love to hear your thoughts about our clinic and how we can help better serve you. Please fill out the survey form below…thank you!

Please provide your contact info:

First Name *

Last Name *

Phone Number *

Which location did you visit?AlexandriaPinevilleJena

What was the date of your visit? *

Month

Day

Year

How would you rate :

Overall quality of medical care? *ExcellentGoodFairPoor

Courtesy and helpfulness of front desk staff? *ExcellentGoodFairPoor

Courtesy and professionalism of nursing staff? *ExcellentGoodFairPoor

During your visit, were you periodically informed of the status of your treatment & offered water or other conveniences? *YesNo

Based on your recent appointment, how would you rate your PROVIDER?

Listens to you *ExcellentGoodFairPoor

Takes enough time with you *ExcellentGoodFairPoor

Explains your plan of care *ExcellentGoodFairPoor

Satisfaction with your plan of care *ExcellentGoodFairPoor

Cleanliness and neatness of Premier Urgent Care? *ExcellentGoodFairPoor

Clear communication and instructions during visit? *ExcellentGoodFairPoor

Wait time in – WAITING ROOM *ExcellentGoodFairPoor

Wait time in – EXAM ROOM *ExcellentGoodFairPoor

Was the cost of your visit reasonable?YesNo

Overall, how would you rate your experience? *ExcellentGoodFairPoor

How likely would you be to refer to friends & relatives? *Very likelySomewhat likelySomewhat unlikelyNot at all likely

Overall, were you satisfied enough to return to our center for medical care in the future? *YesNo

Would you be willing to share your experience in Premier Urgent Care marketing intiatives? *YesNo

What was the date of your visit? *

Month

Day

Year

We'd like to hear any comments you might have about your visit to our clinic. *

To improve our services and better service our clients, we may wish to contact you regarding your feedback. What is your email address?(Note that your email address will only be used to contact you if appropriate and will not be used for any other purpose.)

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